Wiki Cerumen removal and 99354

hsmith67

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I have a debate going that I would like some feedback on and please provide references whenever possible.

Primary care setting, patients with ear pain, problems hearing, etc that upon physical exam have impacted cerumen.

Scenario 1: Provider irrigates patient ear/s, uses sucker, whatever he/she can to get impacted cerumen out of ear. This is after chief complaint, history, physical exam, etc. Provider spends 35 minutes to 1 hour face total face with patient.

Scenario 2: Provider does same as scenario 1 above, but also uses curette to remove cerumen. Provider spends 35 minutes to 1 hour total face to face with patient.

Scenario 3: Provider does chief complaint, history, physical exam, etc and advises nurse to remove cerumen. Nurse uses irrigation/sucker, etc. and removes impacted cerumen. Provider spends 15-20 minutes total face to face with patient, nurse then spends 30 minutes to 1 hour total face to face with patient.

I have had no success getting 69210 paid in any scenario except when billed by itself (no E&M code billed). Even though the CPT book does not define 69210 as using "curette or surgical instruments" I have read that is what payers expect and how they interpret 69210. My thought is to bill 99213 and 99354 for additional time spent for Scenario 1 and 2. However, if the nurse performs the procedure in Scenario 3 then I can only bill 99213 and the 30 minutes to 1 hour face to face time spent by the nurse is 100% "freebie" as there is no way to bill that time (can't bill 99354 for nurse face to face time as nurse is not "physician or other qualified health care professional"). So procedure is done essentially for free.

I just want to get my providers the most reimbursement possible for time spent (by all parties) and play by the rules. So...Please, let me know your thoughts.

Thanks for any help/references you can provide.

Hunter Smith, CPC
 
cerumen removal

I have a debate going that I would like some feedback on and please provide references whenever possible.

Primary care setting, patients with ear pain, problems hearing, etc that upon physical exam have impacted cerumen.

Scenario 1: Provider irrigates patient ear/s, uses sucker, whatever he/she can to get impacted cerumen out of ear. This is after chief complaint, history, physical exam, etc. Provider spends 35 minutes to 1 hour face total face with patient.

Scenario 2: Provider does same as scenario 1 above, but also uses curette to remove cerumen. Provider spends 35 minutes to 1 hour total face to face with patient.

Scenario 3: Provider does chief complaint, history, physical exam, etc and advises nurse to remove cerumen. Nurse uses irrigation/sucker, etc. and removes impacted cerumen. Provider spends 15-20 minutes total face to face with patient, nurse then spends 30 minutes to 1 hour total face to face with patient.

I have had no success getting 69210 paid in any scenario except when billed by itself (no E&M code billed). Even though the CPT book does not define 69210 as using "curette or surgical instruments" I have read that is what payers expect and how they interpret 69210. My thought is to bill 99213 and 99354 for additional time spent for Scenario 1 and 2. However, if the nurse performs the procedure in Scenario 3 then I can only bill 99213 and the 30 minutes to 1 hour face to face time spent by the nurse is 100% "freebie" as there is no way to bill that time (can't bill 99354 for nurse face to face time as nurse is not "physician or other qualified health care professional"). So procedure is done essentially for free.

I just want to get my providers the most reimbursement possible for time spent (by all parties) and play by the rules. So...Please, let me know your thoughts.

Thanks for any help/references you can provide.

Hunter Smith, CPC

Hi Hunter-
I have always used 69210 with my E/M code and 25 modifier for cerumen removal when it's removed using currette or other spoon/instrument. I learned in my coding certification class (few years back: 2007) that 69210 is not for ear lavage/aspiration-the work for that is captured in the E/M. It's only when a currette/spoon is used by the physician that 69210 is billable.
 
69210 and E&M continued

Kristina,

Thanks for response. Are you telling me your payers will pay BOTH an E/M and 69210? I've tried with a 25 on the E/M and without. With different DX codes and with same DX (on E/M and 69210) and payers will pay one code or the other but not both.

I guess I'm to assume since it appears you are getting paid both E/M and the 69210 you are not billing the "additional time" spent 99354. My issue in a nutshell is I can either get ~$65-70 for the OV or ~$50 for the 69210 but I can't get a penny more for both codes being billed and the visit can take a total of 45 minutes to an hour 15 minutes. Basically, provider gets paid the same for a 15 minute 99213 but yet this "encounter" ties up the room for an hour to an hour and fifteen minutes. It just seems there has to be a better way to bill and get paid more than $50-70 for over an hour with the patient. I have appealed this issue with my local BCBS (by far the largest commercial payer in NC) and lost. I'm just looking for another way to get more reimbursement for an hour of time spent for my providers.

Do you, or anyone else see an issue with me billing a 99213 + 99354 given the history of payers paying only the E/M or the 69210 but not both?

By the way, thanks for the clarification on the lavage included in the E/M and 69210 = instruments used. That helps me with that debate, but can you provide me a reference I can show my docs since the CPT book does not define 69210 as requiring instruments?

Thanks,
Hunter
 
You cannot substitute the 99354 for a procedure code that is not being paid. If your payers are paying either the visit level or the 69210 then you need to appeal with documentation to support that the elements of a 69210 have been performed, and the criteria for a separate visit have been met. The reason one is being denied is due to trending. The national trend supports that this is either performed by nursing staff and does not qualify, or is an irrigation which does not qualify, or the visit does not meet the criteria for the use of the 25 modifier and does not qualify. If you have all your ducks in a row and everything is there to support both codes then you need to appeal to show the payers that yopur trend in your office is different.
The Coders Desk reference and the CPT assistant both provide excellent definitions of the 69210 which shows that instruments must be used.
 
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